Khek Yu Ho

Preoperative diagnosis of a paraesophageal bronchogenic cyst using endosonography

Preoperative diagnosis of paraesophageal bronchogenic cysts is difficult, and its management remains controversial. We describe the case of an incidental paraesophageal bronchogenic cyst, suspected preoperatively with endoscopic ultrasound and established intraoperatively by thoracoscopic inspection. Surgical treatment was achieved by cyst excision using a needlescopic technique. Endoscopic ultrasound seems to be the preoperative diagnostic test of choice for paraesophageal bronchogenic cysts.

Features that may predict hospital admission following outpatient therapeutic ERCP

BACKGROUNDnSome patients are admitted following outpatient therapeutic ERCP because of adverse events. This study aimed to identify factors that may predict such admissions.nnnMETHODSnWe prospectively studied admissions for post-ERCP adverse events in 415 consecutive patients undergoing outpatient therapeutic ERCP. Potentially relevant predictors of admission were assessed by univariate analysis and in case of significance included in a multivariate analysis.nnnRESULTSnAdmission was necessary in 41 patients (9.9%) because of complications and in 63 (15.2%) for observation of adverse events that did not progress to definable complications. Potential predictors of admission were evaluated comparing patients who required more than an overnight admission (n = 63) with those who did not (n = 352). Multivariate analysis identified three factors that were significant: pain during the procedure (odds ratio 3.8: 95% CI [1.8, 7.9]), history of pancreatitis (odds ratio 2.3: 95% CI [1.1, 4.7]) and performance of sphincterotomy (odds ratio 2.2: 95% CI [1.1, 4.3]). The presence of all these features was associated with a 66.7% likelihood of admission, whereas the absence of pain during the procedure, history of pancreatitis and performance of sphincterotomy made admission likely in only 11.0%, 9.8% and 10.7%, respectively, of the cases.nnnCONCLUSIONSnThe occurrence of pain during the procedure, a history of pancreatitis and the performance of sphincterotomy were independent predictors of admission following outpatient therapeutic ERCP.

Risk Factors for Barrett's Oesophagus

Background: Barretts oesophagus (BO) is a premalignant condition associated with the development of oesophageal adenocarcinoma (OAC). Globally, the incidence of OAC is rising. Furthermore, the prognosis regarding the morbidity and mortality of OAC is bleak, with an estimated 5-year survival of 10-15%. Hence, detection of the premalignant phase is paramount. Endoscopy and biopsy sampling is the mainstay of diagnosis. Patients may present with symptoms of gastro-oesophageal reflux disease (GORD) or be completely asymptomatic. Therefore, symptomatology alone is a poor indicator of this condition. Summary: This review highlights the current risk factors associated with the development of BO. Key Message: Primary risk factors for BO include male gender, increased age, a family history of the disease, long-standing GORD, smoking, obesity (specifically determined by the waist-to-hip ratio as opposed to BMI), and Caucasian race. Alcohol consumption and Helicobacter pylori are not associated with the condition. Practical Implications: By ensuring an appropriate understanding of the risk factors, clinicians can discern at-risk patients for endoscopic diagnosis and surveillance.

Risk stratifying the screening of Barrett's esophagus: An Asian perspective: Screening Barrett's esophagus

Barretts esophagus (BE) is a premalignant condition for esophageal adenocarcinoma. Although risk factors exist for screening patients in the West, we aimed to determine the factors in terms of demographics and symptoms for patients in an Asian setting.

The Medical Management of Gastro-Oesophageal Reflux Disease

Background: Gastro-oesophageal reflux disease (GORD) is a common global phenomenon. It is associated with the backflow of gastric contents proximally, typically due to transient relaxations of the lower oesophageal sphincter. Various factors contribute to GORD, including obesity, smoking, alcohol and pregnancy. The primary concern of GORD is its association with the development over time of Barretts oesophagus and, ultimately, oesophageal adenocarcinoma. Summary: This review focuses on the various medical interventions that are useful in the treatment of GORD. Key Messages: Various lifestyle interventions such as weight loss and smoking cessation are useful in the treatment of GORD. Medical therapy relies on the use of acid suppressants such as proton pump inhibitors and histamine H2 receptor antagonists.

Recent Updates in the Endoscopic Diagnosis of Barrett's Oesophagus

Background: Barretts oesophagus (BO) is a premalignant condition associated with the development of oesophageal adenocarcinoma (OAC). Despite the low risk of progression per annum, OAC is associated with significant morbidity and mortality, with an estimated 5-year survival of 10%. Furthermore, the incidence of OAC continues to rise globally. Therefore, it is imperative to detect the premalignant phase of BO and follow up such patients accordingly. Summary: The mainstay diagnosis of BO is endoscopy and biopsy sampling. However, limitations with white light endoscopy (WLE) and undertaking biopsies have shifted the current focus towards real-time image analysis. Utilization of additional tools such as chromoendoscopy, narrow-band imaging (NBI), confocal laser endomicroscopy (CLE), and optical coherence tomography (OCT) are proving beneficial. Furthermore, it is also becoming more apparent that often these tools are utilized by experts in the field. Therefore, for the non-expert, training in these systems is key. Currently as yet, the methodologies used for training optimization require further inquiry. Key Message: (1) Real-time imaging can serve to minimize excess biopsies. (2) Tools such as chromoendoscopy, NBI, CLE, and OCT can help to compliment WLE. Practical Implications: WLE is associated with limited sensitivity. Biopsy sampling is cost-ineffective and associated with sampling error. Hence, from a practical perspective, endoscopists should aim to utilize additional tools to help in real-time image interpretation and minimize an overreliance on histology.

Transbronchial Needle Aspiration Followed Immediately by Endoscopic Ultrasound Guided Needle Aspiration in the Evaluation of Mediastinal Lymphadenopathy

Transbronchial Needle Aspiration Followed Immediately by Endoscopic Ultrasound Guided Needle Aspiration in the Evaluation of Mediastinal Lymphadenopathy Khay L. Khoo, Khek Y. Ho, Tow K. Lim Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is a useful diagnostic tool in the evaluation of mediastinal lymphadenopathy, both as a primary modality and in cases of negative transbronchial needle aspiration (TBNA). Aim: To determine the utility of TBNA with rapid on-site cytopathologic evaluation (ROSE) combined with the option for immediate EUS-FNA in the diagnosis of mediastinal adenopathy of unknown etiology. Methods: We prospectively enrolled patients with mediastinal lymphadenopathy on CT scan who required cytologic evaluation. We first performed flexible videobronchoscopy with TBNA. If TBNA was inadequate on ROSE, EUS-FNA was performed immediately, all under topical anesthesia, conscious sedation, and in the same outpatient sitting. The same cytotechnologist was in attendance during both the consecutive procedures to make smears for instant examination. The procedures were terminated when adequate cellular specimens were achieved, or a maximum of six needle passages was done. Results: Twenty patients with mediastinal lymphadenopathy on chest CT underwent TBNA with ROSE. The TBNA specimens were adequate in 13 patients. In the remaining 7 patients, TBNA with ROSE was assessed to be inadequate; thus, EUS-FNA was also performed. Upon cytologic confirmation, TBNA with ROSE was falsely negative in one patient. The diagnostic yield of TBNA was thus 70%. EUS-FNA was positive in 6 of 7 patients, giving a diagnostic yield of 86%. Overall, this combined minimally invasive approach to mediastinal lymphadenopathy, which was well tolerated by all patients with no adverse effects, provided a diagnostic yield of 90%. The final diagnoses were non-small cell cancer (nZ 11), small cell cancer (nZ 2), metastatic adenocarcinoma (nZ 1), sarcoidosis (nZ 1), tuberculosis (nZ 1), and lymphoma (n Z 1). In the first case where this approach failed to give a diagnosis, TBNA showed lymphocytes but interval CT did not show progression of the lymphadenopathy. The second patient had non-small-cell lung cancer. Conclusions: TBNA with ROSE combined with the option for back-to-back EUS-FNA raised the diagnostic yield of TBNA alone from 70% to 90%. This combined approach is safe, convenient and potentially cost-effective for the patient, who needs not undergo another procedure on another day. Abstracts

7229 Eus performed without luminal water filling is as accurate for staging depth of invasion in gastric carcinoma.

Presently endoscopic ultrasound (EUS) is the most accurate modality for T staging of gastric carcinoma. Two acoustic coupling techniques are used: (1) balloon-inflation alone, and (2) luminal water filling plus balloon-inflation. Not filling the gastric lumen with water may have the advantages of improved comfort for the patient, and a reduced risk of aspiration. However effect of omitting luminal water on the accuracy of gastric cancer staging has not been evaluated. AIM: To determine if the non-luminal filling technique was as accurate as the conventional waterfilled lumen technique in the T staging of gastric carcinoma. METHODS: Preoperative EUS was performed on 26 consecutive patients (aged 30-89 years, median 64 years) with gastric carcinoma by two experienced operators, using a radial echoendoscope (GF-UM200, 7.5-12 MHz, Olympus Co. Ltd, Singapore). The non-luminal filling technique (HKY) and the water-filled lumen technique (YKG) were used in 14 and 12 patients respectively. In the water-filled lumen procedures, 200-300 ml water was pumped into the stomach. The findings were prospectively correlated with histology of the resected specimens. RESULTS: Of the 26 tumors, 3 were pathologic (p) T1, 2 pT2, 15 pT3 and 6 pT4. The overall concordance of EUS T stage with p T stage was 90% for stages pT1 to pT3, while 5 of the 6 pT4 tumors were understaged as T3. Four of the 5 pT4 tumors were impassable antropyloric tumors, and the inability to assess the full length of the tumours was probably the reason for the understaging. The non-water-filled lumen technique was 100% accurate for T staging of pT1 to pT4 tumors versus 80% for the water-filled lumen technique (p = not significant). CONCLUSIONS: Omission of luminal water filling did not reduce the accuracy of EUS in the T staging of gastric carcinoma. This may improve patient safety and comfort.

7230 Impassable antropyloric stricture is predictive of advanced tumor stage.

Presently endoscopic ultrasound (EUS) is the most accurate modality for T and N staging of gastric carcinoma. Of patients with tumors in the antropyloric region, a proportion presents with high-grade strictures that preclude passage of the echoendoscope. It is our impression that these tumors are generally of the advanced stages. However, to our knowledge, this subject has not been formally studied. AIM: To determine the tumor stage of patients presenting with impassable malignant strictures of the antropylorus. METHODS: Preoperative EUS was performed on 30 consecutive patients with gastric carcinoma, using a radial echoendoscope (GFUM200, Olympus Co. Ltd., Singapore). The results of preoperative staging were prospectively compared with pathologic stage of the gastrectomy specimen when available, the surgical specimen or metastatic disease at the time of surgery. RESULTS: Of the 30 gastric carcinoma, 18 (60%) were located in the antropyloric region, 8 in the corpus and the rest in the cardia. Of the antropyloric tumors, 7 (39%) presented with stenoses that precluded passage of the echoendoscope. Staging of the proximal aspect of the tumor was obtained in all of these patients, however, the TNM staging accuracy for such incomplete staging was only 29% (2 of 7). Correct T assessment was obtained in only 4 such patients (57%). In contrast, the T staging accuracy in those patients with antropyloric carcinoma presenting with less severe stricture that allowed passage of the echoendoscope was 82%. By histologic examination of the surgical specimen, 5 of the 7 patients with impassable antropyloric strictures had stage IV disease while 2 had stage III disease. In contrast, the proportions of patients with passable tumors that had stage I, II, III and IV diseases were 3, 3, 2 and 3 respectively (p

4495 Conventional colonoscopy with indigo carmine spray can distinguish adenomatous from hyperlastic polyps: a prospective study.

Chromoendoscopy using a high-resolution colonoscope has been reported to be accurate in distinguishing adenomatous (AP) from hyperplastic polyps (HP). There are few published reports on the use of conventional colonoscopes with chromoendoscopy for such an indication. If conventional colonoscopes with dye-spray can distinguish polyp type, this will make chromoendoscopy more acceptable as a screening tool, since most centers in the world do not possess high-resolution colonoscopes, which are also more expensive and cumbersome. Aim: To determine if chromoendoscopy using conventional video-colonoscopes was accurate in differentiating AP from HP. Methods: All patients found to have polyps ≤ 10 mm on routine colonoscopy using a conventional video-colonoscope (CF230L, Olympus Singapore) were included in the study. The polyps were sprayed with 5 ml of 0.04% indigo carmine solution (Hope Pharmaceutical, Arizona) and removed with either biopsy or snare polypectomy. The endoscopist classified the polyps based on endoscopic surface appearances of sulci or pit. The chromoendoscopic appearances were correlated with the histologic findings. Results: 93 polyps (mean±SD diameter, 5.0±3.7 mm) were evaluated from 70 patients. 3 polyps were excluded because no endoscopic prediction or histologic diagnosis could be made. The sensitivity, specificity, positive and negative predictive values of this chromoendoscopic classification in distinguishing AP from HP were 90%, 89%, 97% and 71%, respectively. Conclusion: Conventional colonoscopes in combination with indigo carmine spray is accurate in separating AP from HP.